Healthcare Provider Details

I. General information

NPI: 1306423314
Provider Name (Legal Business Name): ROHAN BANSAL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2021
Last Update Date: 06/20/2022
Certification Date: 06/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8704 RIDGELAND AVE
OAK LAWN IL
60453-1068
US

IV. Provider business mailing address

8704 RIDGELAND AVE
OAK LAWN IL
60453-1068
US

V. Phone/Fax

Practice location:
  • Phone: 708-430-4440
  • Fax:
Mailing address:
  • Phone: 708-430-4440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number018002174
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019033432
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: